Healthcare Provider Details

I. General information

NPI: 1770812158
Provider Name (Legal Business Name): SANTA FE BLISS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2009
Last Update Date: 12/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 E PALACE AVE SUITE C
SANTA FE NM
87501-2221
US

IV. Provider business mailing address

301 E PALACE AVE SUITE C
SANTA FE NM
87501-2221
US

V. Phone/Fax

Practice location:
  • Phone: 505-820-1572
  • Fax:
Mailing address:
  • Phone: 505-820-1572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1528
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number3377
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number938
License Number StateNM

VIII. Authorized Official

Name: MR. WYATT WEGRZYN
Title or Position: MANAGER
Credential:
Phone: 505-820-1572